Philadelphia Insurance Companies

Philadelphia Insurance Companies One Bala Plaza, Suite 100, Bala Cynwyd, Pennsylvania 19004 610-617-7900 Fax: 610-617-7940

SPECIAL EVENT SUPPLEMENTAL APPLICATION

PIIC Producer: Broker:

Submission Requirements: 1.  Currently valued, carrier-generated Loss Runs for the current year and the last three years (for accounts where premium exceeds $5,000). 2.  Copy of rental agreement or contract to rent or use venue.

Account Information

Applicant Name: Address: Web Site: www. E-Mail Address: Contact Person (Billing): Phone: Contact Person (Loss Control): Phone: Effective Dates Requested: Event Gross Revenues: $

For Profit:  Individual  Partnership  Corporation  Association  Other: Non-Profit:  Years this entity in Years experience of this owner: business: Has the applicant had any claims filed against it in the last four years? Yes  No  If yes, please provide details:

1. Description of Event

2. Dates: Times: (Attach brochure or promotional materials if applicable.)

Total Number of Attendees Number of Attendees per day: Total Number of Volunteers Number of Volunteers per day:

Revenue Generated: Admission Fees $ Liquor Sales $ Food Sales $ Merchandise $

3. Is alcohol being served? Yes  No  By whom? Has server provided evidence of liquor liability insurance? Yes  No  Is Liquor Liability coverage desired? Yes  No  If Yes, complete liquor liability supplement.

Amateur Sports Special Event Page 1 of 2 1/05 Supplemental Application 4. Name of Venue: Seating Capacity Seating Type (Permanent Grandstands, Temporary Bleachers) Number of Exhibitors Who is supplying security at venue? (If private firm, they must have insurance and name you as an additional insured.) Describe the safeguards in place to prevent injury to spectators:

Describe first aid/medical arrangements:

5. Is the event limited to venue grounds? Yes  No  If no, provide details: Describe first aid/medical arrangements:

6. Swimming: Yes  No  If Yes, are certified lifeguards on duty? Yes  No  Are they CPR trained? Yes  No  Are certificates received by Insured? Yes  No 

7. Athletic Events Yes  No  If Yes, is athletic participant coverage desired? Yes  No 

8. Performers Yes  No  If yes, please list all performers:

9. Are you required to provide certificates of insurance to any other entity? Yes  No  If yes, please provide names of certificate holders and their interest:

10. Other Comments:

Applicant’s Statement and Declarations The applicant declares to the best of his / her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein.

Applicant’s Signature Date Broker’s / Agent’s Signature Date

Amateur Sports Special Event Page 2 of 2 1/05 Supplemental Application